Risk factors for ocular hypotony after XEN Gel Stent implantation.

PURPOSE: To investigate the incidence of postoperative hypotony, and risk factors for the development of hypotony in eyes who had undergone XEN Gel Stent implantation. METHODS: In this retrospective, single-centre case series, medical records of 170 consecutive eyes who had undergone XEN Gel Stent implantation with or without simultaneous phacoemulsification for primary or secondary open angle glaucoma were analysed. Primary outcome parameters were the incidence of postoperative hypotony and potential risk factors for its development, and secondary parameters were pre- and postoperative visual acuity, intraocular pressure (IOP), and number of IOP-lowering eye drops. RESULTS: Postoperative hypotony ≤ 6 mmHg occurred in 57% of eyes. Hypotony was without complications in 70.1%, 13.4% had transient complications with spontaneous resolution, and 16.5% had complications requiring treatment. Mean visual acuity logMAR before surgery accounted for 0.47 ± 0.46 in all eyes and 0.47 ± 0.48 at the 4-week visit. There was no significant difference of BCVA in the group of eyes with and without postoperative hypotony before and after surgery. The mean IOP before surgery was 24.6 ± 8.4 mmHg and decreased significantly to 18.4 ± 10.2 after 4 weeks. Eyes with an axial length over 24.3 mm had a threefold increased risk for postoperative hypotony (OR 3.226, 95% confidence interval 1.121-9.279). This risk was decreased in eyes with simultaneous cataract surgery (OR 0.483, 95% confidence interval 0.258-0.903). CONCLUSION: In our sample, postoperative hypotony was a common complication after XEN Gel Stent implantation, but serious, persistent complications were rare. A longer axial length predisposes the eye for the development of hypotony.

The effects of the first versus second glaucoma drainage implant surgery in patients with primary open-angle glaucoma.

BACKGROUND: To investigate the outcome of non-valved glaucoma drainage implant surgery (GDIS) in primary open-angle glaucoma (POAG) patients divided in the first GDI group (patients who underwent the first GDIS) and the second GDI group (patients who underwent the second GDIS because of the failed first GDIS). METHODS: Intraocular pressure (IOP), visual acuity (VA), visual field defect (VFD), medication score (MS), survival rate of GDIS, complications, and patient background was retrospectively analyzed. Two success criteria were set: Criteria (1) IOP reduction ≥ 20% and 5 < IOP ≤ 21, Criteria (2) IOP reduction ≥ 20% and 5 < IOP ≤ 14. RESULTS: There were 136 eyes of 109 patients in the first GDI group and 32 eyes of 27 patients in the second GDI group. In the first GDI group and II, mean preoperative IOP was 26.7 ± 6.7 mmHg and 23.7 ± 3.5 mmHg, respectively (P = 0.09). No statistically significant difference in postoperative IOP reduction was found between the two groups (P = 0.39). At 5-years postoperative, the Criteria 1 (Criteria 2) survival rate in the first GDI group and the second GDI group was 60.4% (31.7%) and 61.2% (25.6%), respectively (Criteria 1: hazard ratio [HR]: 0.64, 95% confidence interval [CI]: 0.30-1.35 [P = 0.24]; Criteria 2: HR: 0.81, 95% CI: 0.46-1.44, P = 0.48). No significant difference in VA, VFD change, MS, or complications was observed. Young patient age was the only significant factor for failure in the first GDI group (odds ratio: 0.95, 95% confidence interval: 0.91-1.00, P = 0.03). CONCLUSION: The second GDIS may be as effective as the first GDIS for IOP reduction in POAG patients, however, there is a high risk of failure in young-age patients and the surgery may be ineffective in eyes requiring Criteria 2.

Clinical outcomes of the PAUL® glaucoma implant: One-year results.

BACKGROUND: To report one-year outcomes from a single-centre cohort undergoing PAUL® Glaucoma Implant (PGI) surgery. METHODS: Retrospective review of patients undergoing PGI surgery at the University Eye Hospital Bonn, Germany, from April 2021 to September 2021. RESULTS: Forty-five eyes of 41 patients were included. Qualified and complete success rates (95% CI) were 95.6% (88.9%-100%) and 73.3% (60%-86.7%) for Criterion A (IOP ≤ 21 mmHg), 84.4% (73.3%-93.3%) and 74.4% (51.1%-80.0%) for Criterion B (IOP ≤ 18 mmHg), 62.2% (48.9%-75.6%) and 46.7% (31.2%-62.2%) for Criterion C (IOP ≤ 15 mmHg) and 26.7% (13.3%-40.0%) and 22.2% (11.1%-33.3%) for Criterion D (IOP ≤ 12 mmHg), respectively. Mean IOP decreased from 26.1 mmHg (7-48 mmHg) to 12.0 mmHg (3-24 mmHg) (reduction of 48.83%) after 12 months with a reduction of IOP-lowering agents from 0.5 (0-3). One eye (2.2%) needed an injection of viscoelastic due to significant hypotony with AC shallowing, and four eyes (8.9%) developed choroidal detachments due to hypotony which resolved without further interventions after 6 weeks. Three patients (6.7%) developed tube exposure which required conjunctival revision with an additional pericardial patch graft. An intraluminal prolene stent was removed in 19 eyes (42.2%) after a mean time period of 8.4 months (2-12 m). Mean IOP before the removal was 21.9 mmHg (12-38 mmHg) and decreased to 11.3 mmHg (6-16 mmHg). CONCLUSIONS: PGI surgery is an effective procedure for reducing IOP and pressure-lowering therapy. An intraluminal prolene stent impedes hypotony in the early postoperative phase and enables further IOP lowering without additional interventions during the postoperative course.

Two-Year Outcome of Surgery in Glaucoma Patients.

PURPOSE: To evaluate the 2-year surgical treatment outcome in glaucoma patients. METHODS: A retrospective, single-center, interventional study was performed on 160 eyes of 125 patients suffering glaucoma, including POAG (82 eyes), pseudoexfoliation (PEX) (59 eyes), pigment dispersion (8 eyes), and secondary glaucoma (2 eyes). Eyes with uncontrolled intraocular pressure (IOP) or signs of glaucoma progression despite medical treatment were included to undergo either trabeculectomy (TE), XEN implantation, combined TE with phacoemulsification (TE + IOL), or XEN implantation with phacoemulsification surgery (XEN + IOL). Primary efficacy outcome was the mean IOP reduction. Secondary outcome was the mean reduction in the number of medications. The data were compared at baseline vs.1 day, 1 week, and 1, 3, 6, 12, and 24 months following surgery. For statistical evaluation, ANOVA-based linear mixed-effects models were performed with SPSS. RESULTS: The mean IOP reduction in a 2-year follow-up was 30.31% (22.17 vs. 15.45 mmHg, p < 0.001). The mean number of antiglaucoma medications was reduced from 2.87 to 0.58 (p = 0.001), where TE alone or combined surgeries seemed to be more effective than isolated XEN surgery. Transient IOP hypotony on the first postoperative day occurred in PEX patients following TE surgery (p = 0.024). At 6 months, PEX patients with isolated XEN surgery showed a transient IOP increase, whereas those after combined TE + IOL surgery showed the lowest IOP within the PEX group compared to other glaucoma patients (p < 0.026). CONCLUSIONS: After 2 years, all performed glaucoma surgeries achieved a significant reduction in IOP and the number of antiglaucoma medications.

Posttraumatic Ocular Hypotony Through Epithelial Downgrowth. / Posttraumatische Bulbushypotonie durch Epithelinvasion.

BACKGROUND: Intraocular epithelial downgrowth is a rare but potentially devastating posttraumatic complication. If left untreated, this may result in corneal decompensation, secondary angle-closure glaucoma, retinal detachment and blindness. PATIENT AND METHOD: A 10-year-old patient with penetrating globe injury and delayed wound management elsewhere presented with corneal melting and decompensation, retinal detachment and ocular hypotony. Following penetrating keratoplasty, cyclopexy and vitrectomy, corneal melting in the interface with renewed retinal detachment was noted within days. The hopeless prognosis required enucleation of the globe. RESULTS: Optical coherence tomography revealed not only corneal melting, but also markedly hyperreflective structures posterior to the cornea. Immunohistology demonstrated diffuse multi-layered nonkeratinised squamous cell epithelium on the posterior corneal surface, iris, ciliary bodies, and retina, as well as below the choroid, with renewed tractional retinal detachment. CONCLUSION: Posttraumatic epithelial downgrowth may result in tractional retinal detachment, cyclodialysis cleft and/or corneal melting. Hyperreflective membrane deposits on OCT may be indicative of diffuse epithelial downgrowth. Especially in children, prompt wound closure in globe injuries is vital to avoid this serious posttraumatic complication.

Analysis of risk factors and ocular hypotony characteristics in choroidal detachment after penetrating glaucoma surgery.

PURPOSE: To analyze the risk factors and ocular hypotony characteristics of choroidal detachment (CD) after penetrating glaucoma surgery and to compare between eyes with and without CD. METHODS: This retrospective study enrolled 173 eyes of 168 patients. Patients who underwent trabeculectomy or Ahmed glaucoma valve implantation due to medically uncontrolled glaucoma and who had intraocular pressure (IOP) < 9 mmHg at any time during the first postoperative week were included. RESULTS: The study population consisted of 61 (36.3%) females and 107 (63.7%) males with a mean age of 60.7 ± 14.2 years. The postoperative median follow-up time was 24 months (range, 12-40 months). Postoperatively, CD developed in 47 (27.1%) eyes. Multivariate analyses demonstrated that eyes with high preoperative IOP (> 40 mmHg) were 12.1 times more likely to develop CD (p = 0.000) and that presence of IOP < 9 mmHg on the first day of surgery increased the CD risk 3.8 times (p = 0.002); male gender raised the risk 2.7 times (p = 0.028). The mean preoperative IOP in CD eyes was significantly higher than in non-CD eyes (p = 0.000). The mean IOP change between preoperative and lowest IOP was significantly greater in those with CD than in those without CD (p = 0.000). The mean lowest IOP in the CD eyes was significantly lower than in the non-CD eyes (p = 0.037). For the surgical failure rate, no significant difference was found between the CD and the non-CD groups (p = 0.14). CONCLUSIONS: The present study demonstrated that high preoperative IOP, presence of IOP < 9 mmHg on the first postoperative day, and male gender were significantly associated with CD after penetrating glaucoma surgery. Choroidal detachment accompanied by hypotony did not affect the final outcome negatively.

Pressure restoration and visual recovery time in hypotony after trabeculectomy.

OBJECTIVES: To asses the course of intraocular pressure (IOP) restoration and visual acuity (VA) recovery in eyes with hypotony after trabeculectomy. METHODS: Medical charts of patients undergoing trabeculectomy between January 2017 and June 2019 were reviewed. Cases with hypotony (IOP < 5 mmHg) due to over-filtration in the early postoperative period were assessed retrospectively. Primary outcome measures included change in IOP and VA in the postoperative period and percentage of eyes with hypotony on each follow-up. RESULTS: Thirty-five eyes of 31 patients (23 male, 8 female) were included. The mean follow-up was 18.3 ± 6.9 months. The mean IOP was 3.0 ± 3.2, 9.2 ± 6.2, 9.4 ± 5.6, 9.4 ± 4.0, 10.9 ± 3.6 and 10.2 ± 3.3 mmHg at week 1, months 1, 3, 6, 12 and last follow-up, respectively. Out of 35 hypotonic eyes, 8 (22.8%) had prolonged hypotony at month 1, 4 (11.4%) at month 3, 1 (2.9%) at month 6. The decrease in VA continued to be significant at months 1 and 3 (p = 0.015, p = 0.036, respectively) and returned to baseline after the sixth month (p > 0.524). CONCLUSIONS: In eyes with early hypotony after trabeculectomy while low IOP recovers at first month, it takes longer for the visual restoration. The postoperative month 1 appears to be decisive for recovery of hypotony.

Development of a rabbit model of persistent hypotony without ciliary body injury.

In order to study the pathophysiological alterations of the ciliary body (CB) during persistent hypotony, it is necessary to develop an animal model without CB injury. In this study, we successfully established a modified model of persistent hypotony without CB injury in New Zealand rabbits. A 23-gauge pars plana vitrectomy (PPV) was performed and a trocar-formed fistula was allowed to remain in situ, to produce a continuous outflow of intraocular fluid. Both eyes underwent PPV with normal intraocular pressure (IOP); eyes with no surgical intervention were used as controls. The IOP was monitored and used to evaluate the reliability of the model. Secondary changes of hypotony were evaluated by slit-lamp biomicroscopy and B scans while morphological changes of the CB were observed by haematoxylin and eosin staining. The mean IOP in the hypotony groups were consistently lower than 6 mmHg. Furthermore, there were no significant differences in IOP between the PPV control group and normal eyes. Collectively, our data indicate that this model successfully simulates the secondary changes of hypotony, including a reduction in corneal size, corneal oedema, anterior chamber inflammation, morphological alterations of the CB, cataract, retinal detachment, and choroidal detachment. The morphological structure of the CB tissue changed dramatically after persistent hypotony, indicating that normal IOP may be required in order to maintain normal function in the CB. This model of persistent hypotony potentially represents a valuable tool for future studies aiming to investigate the pathophysiological mechanisms underlying CB dysfunction and other secondary changes that occur during hypotony.

Intraocular endoscopy for the evaluation and treatment of hypotony due to a traumatic cyclodialysis: a case report.

BACKGROUND: A cyclodialysis cleft often leads to direct communication between the anterior chamber and the suprachoroidal space. It is a rare condition that is encountered with blunt trauma, and less commonly, after surgery. Hypotony is the major sequelae that may lead to hypotonous maculopathy, optic disc edema, corneal folds, and astigmatism. These may cumulatively lead to visual loss. We describe how endoscopy in a cyclodialysis repair allowed us to accurately locate the cleft and guided its appropriate management avoiding unnecessary cryopexy. CASE PRESENTATION: A 41-year-old male experienced a traumatic cyclodialysis cleft, which resulted in persistent hypotony. Pars plana vitrectomy was performed to treat vitreous hemorrhage. Scleral indentation was attempted to visualize the cyclodialysis cleft. However, the depression distorted the visualization. Intraocular endoscopy was therefore used to evaluate the cleft. Guided by this assessment, only intraocular gas tamponade was used to reposition the ciliary body. The patient's intraocular pressure was restored to 13 mmHg 3 days after the operation, and OCT confirmed cleft closure 1 month after the operation. CONCLUSION: Endoscopy-assisted repair of cyclodialysis is an approach that enhances visualization and can guard against common causes of persistent cleft and hypotony, as well as reveal the causes of recurrent failure. Hence, it can eliminate unnecessary cryopexy that might worsen the hypotonous state. In our case, intraocular endoscopy was effective for the evaluation of a cyclodialysis cleft and the subsequent selection of an appropriate management technique, gas tamponade, that was more conservative than other approaches initially considered.

Ab interno tube ligation for refractory hypotony following non-valved glaucoma drainage device implantation.

PURPOSE: To report the 2-year outcomes of a novel surgical technique allowing reduction of the intraluminal diameter of the tube without total tube occlusion in order to allow enough increase in outflow resistance to permit resolution of hypotony whilst also achieving adequate IOP control. METHODS: This was a single-surgeon retrospective case note review of all non-valved GDD cases over an 8-year period (2008-2015) that underwent ab interno ligation of the drainage tube in order to manage post-operative hypotony (Baerveldt or Molteno). Twelve eyes of 12 patients (4.4%) developing refractory hypotony that did not respond to multiple intracameral ophthalmic viscoelastic device (OVD) injections were included in this retrospective case series and were treated with our ab interno tube ligation technique. The post-ligation management algorithm consisted of re-instating topical anti-glaucoma agents, laser suture lysis (LSL), or further ab interno ligation. RESULTS: Mean IOP increased from 2.8 mmHg at baseline to 7.8 mmHg, 7.1 mmHg, 9.0 mmHg, 13.6 mmHg, 10.9 mmHg, 13.9 mmHg and 13.6 mmHg at day 1, week 1, month 1, month 3, month 6, year 1 and year 2 respectively, with or without additional topical anti-glaucoma medications. Although hypotony resolution following our technique was achieved in all eyes at 2 years, 8.3% of cases required reinstatement of topical medications to maintain IOP control within the target range. CONCLUSIONS: We propose ab interno partial tube tying as an effective surgical option to achieve an immediate, predictable and sustained IOP elevation either as a primary procedure or when traditional methods have failed to resolve hypotony in eyes with non-valved GDDs.

Prospective study on a novel treatment for leaking cystic bleb: Efficacy and safety of collagen crosslinking.

IMPORTANCE: Management of cystic bleb leak is difficult. It would be essential to look for a method to strengthen the original pathological conjunctiva and reverse bleb leak. BACKGROUND: To evaluate the long-term efficacy and safety of collagen crosslinking in patients with leaking cystic bleb. DESIGN: Prospective interventional case series at a university-based hospital. PARTICIPANTS: Twelve eyes in 12 subjects with late-onset bleb leak from cystic bleb, without indications for prompt surgical interventions were included. METHODS: The subjects underwent crosslinking with 0.1% riboflavin application to bleb surface, followed by ultraviolet irradiation for 30 minutes. The subjects were followed up at baseline and at 1 week, 1 month, 3 months, 6 months post-treatment and then every 6 months afterwards. MAIN OUTCOME MEASURES: Interval from treatment to cessation of bleb leak, recurrence rate of bleb leak and side effects of treatment. RESULTS: The mean follow-up after crosslinking was 29.33 ± 12.45 months. Bleb leak subsided in 11 (92%) of 12 patients after a single session of crosslinking, after 1 to 8 weeks (median 3 weeks). Time to leak cessation was significantly correlated with the number of prior glaucoma interventions (R = .71, P = .014). Bleb wall at 3 months was significantly thicker than at baseline (0.70 ± 0.67 vs 0.81 ± 0.62 mm, P = .008). None of the patients experienced any complications. CONCLUSIONS AND RELEVANCE: Crosslinking achieves resolution of cystic bleb leak which lasts for at least 12 months, without the need of subsequent surgical interventions. Crosslinking is a simple, non-invasive treatment for bleb leak. It aims to restore the integrity of conjunctiva.

Frequency of post-operative hypotony after 23-gauge transconjunctival vitrectomy with locally made instruments.

The objective of this study was to discern the frequency of post-operative hypotony after 23-gauge vitrectomy with locally made instruments. This study was conducted at the Department of Ophthalmology, Lahore General Hospital, Lahore from July 2012 to June 2016. A total of 300 patients underwent 23-gauge pars-plana vitrectomy. Locally made 23-gauge trocar cannula system was used in all the patients. Post-operative Intraocular Pressure(IOP) was measured using Goldman Applanation Tonometer on the first post-operative day. IOP of less than 06mmHg was termed as hypotonic. In our study, mean post-operative intraocular pressure was recorded as 8.32±3.04mmHg and frequency of post-operative hypotony after 23-guage vitrectomy with locally made instruments reveals 10.67% (n=32) while 89.33% (n=268) had no findings of hypotony. We concluded that the frequency of post-operative hypotony after 23-gauge vitrectomy with locally made instruments is slightly higher when compared with other studies and this instrument can be used for further surgeries.

Cyclodialysis cleft repair and cataract management by phacoemulsification combined with internal tamponade using modified capsular tension ring insertion.

PURPOSE: To evaluate the surgical outcomes of cyclodialysis cleft repair and cataract management by phacoemulsification combined with internal tamponade using a modified capsular tension ring (MCTR) compared with direct cyclopexy. METHODS: The preoperative and postoperative characteristics of patients with cyclodialysis clefts who underwent surgery via insertion of an MCTR into the ciliary sulcus (MCTR group; 16 patients, 16 eyes) or direct cyclopexy (DC group; 16 patients, 16 eyes) were recorded. RESULTS: The cyclodialysis extended over 2.6 ± 1.9 clock hours in the MCTR group and 3.5 ± 1.8 clock hours in the DC group (P = 0.094). Postoperatively, the IOP was not significantly different between the MCTR and DC groups (12.9 ± 3.7 mmHg vs. 13.8 ± 6.2 mmHg, P = 0.985); the logarithm of the minimal angle of resolution BCVA was better (0.1 ± 0.2 vs. 1.0 ± 0.9, P < 0.001), and the anterior chamber depth was greater (3.87 ± 0.40 mm vs. 2.59 ± 0.58 mm, P < 0.001) in the MCTR group than in the DC group. Compared with the preoperative parameters, the postoperative BCVA, IOP, and anterior chamber depth values were significantly improved in the MCTR group (P < 0.05), whereas the BCVA showed no significant improvement postoperatively in the DC group (P = 0.174). Logistic regression revealed no significant risk factors for successful IOP control or BCVA improvement. CONCLUSION: Phacoemulsification combined with internal tamponade using MCTR insertion into the ciliary sulcus is a safe and minimally invasive method for effectively closing cyclodialysis clefts and managing cataract.

Outcome of fixed volume intracameral sodium hyaluronate 1.4% injection for early postoperative hypotony after Baerveldt glaucoma implant.

IMPORTANCE: Using an ophthalmic viscoelastic device to manage early postoperative hypotony after Baerveldt glaucoma implant (BGI). BACKGROUND: To determine the outcome of intracameral sodium hyaluronate injection for early postoperative hypotony treatment after BGI. DESIGN: A retrospective study. PARTICIPANTS: One-hundred-and-thirty-eight patients (176 eyes) had BGI from January 2012 to November 2015. Those who had hypotony within 3 months postoperatively were studied. METHODS: Hypotonous eyes were injected with 0.1 mL sodium hyaluronate 1.4% intracameral on the slit-lamp. The patients were followed up weekly and the injection repeated up to 3 times if hypotony persisted. The tube was tied surgically as a last resort. MAIN OUTCOME MEASURES: The intraocular pressure and best-corrected visual acuity at week 1, 2, 3, 4, 6 and month 4 were assessed. RESULTS: Thirty (17.0%) out of 176 eyes developed early postoperative hypotony. The median intraocular pressure and median best-corrected visual acuity when hypotony first presented were 3 mmHg and 0.8 logMAR. Two eyes were excluded as they had more than 0.1 mL injection. Eight (29%) of the 28 hypotonous eyes resolved after one injection, seven (25%) required two and 10 (36%) needed three injections. Three (11%) eyes had surgical tube tie. The median intraocular pressures were 5, 7, 8, 10, 11 and 13 mmHg at week 1, 2, 3, 4, 6 and month 4 post-injection. The median best-corrected visual acuity were 0.60, 0.50, 0.50, 0.45, 0.40 and 0.40 logMAR for the same period. CONCLUSIONS AND RELEVANCE: Standardised intracameral 0.1 mL sodium hyaluronate 1.4% is an effective and safe way to manage early postoperative hypotony after BGI.

[Blinding spontaneous suprachoroidal haemorrhage in anticoagulant taking wet-AMD patients]. / Spontán suprachorioidealis vérzés okozta vakság véralvadásgátló kezelésben részesült idoskori makuladegenerációs betegeken.

We present cases of blinding spontaneous suprachoroidal haemorrhage in anticoagulant taking wet-AMD patients. A retrospective study has been performed to present the clinical course, management and final outcome of spontaneous suprachoroidal haemorrhage in 7 eyes of six age-related macular degeneration patients seen in our clinic from January 2016 to April 2017. All patients were on chronic oral anticoagulant therapy because of cardiovascular disorder. In one patient, haematological disorder was also present modifying significantly the haemostasis. All eyes received prior anti-VEGF treatment for exsudative AMD. Acute angle closure glaucoma - with no response to topical and oral IOP lowering therapy - was the most frequent ocular complication in our cases. The final visual prognosis was usually very poor. The risk of spontaneous suprachoroidal haemorrhage is increased in wet-AMD patients who are on anticoagulant therapy. To prevent this blinding condition, a stronger communication between ophthalmologists and cardiologists would be beneficial, with an ophthalmological check-up in this group of patients before and during the use of anticoagulants. Orv Hetil. 2018, 159(24): 985-990.

Risk Factors and Long-Term Outcomes in Patients with Low Intraocular Pressure after Trabeculectomy.

PURPOSE: To examine risk factors for low intraocular pressure (IOP) after trabeculectomy and to describe long-term outcomes in these eyes. DESIGN: Retrospective case-control study. PARTICIPANTS: Cases with low IOP included all patients with IOP ≤5 mmHg on 3 or more consecutive visits 3 months or later after trabeculectomy. Control patients without low IOP after trabeculectomy were randomly selected at a 1:2 case-to-control ratio. METHODS: A case-control study was performed of patients undergoing trabeculectomy at the Stein Eye Institute. Covariates included demographics, history of cataract surgery, refractive error, number of glaucoma medications, family history of glaucoma, diabetes, hypertension, visual acuity (VA), IOP, number of sutures in the scleral flap, laser suture lysis, surgeon, and laterality of surgery. Logistic regression modeling was used to examine associations between each covariate and low IOP. Postoperative outcomes that were examined included reoperation, vision loss, and surgical failure. The time between trabeculectomy and each outcome was compared between cases and controls with Cox proportional hazards regression modeling. MAIN OUTCOME MEASURES: Low IOP after trabeculectomy, reoperation, vision loss, and surgical failure. RESULTS: Of 3659 total trabeculectomies performed by 5 surgeons between 1990 and 2013, 64 eyes had low IOP (1.7%), which were compared with 130 control eyes. Fifteen of the 64 eyes with low IOP had hypotony maculopathy (23.4%). After accounting for differences in baseline IOP, laser suture lysis was negatively correlated with low IOP after trabeculectomy (odds ratio [OR], 0.33; 95% confidence interval [CI], 0.13-0.87); surgeon was correlated with high vs. low IOP after trabeculectomy (OR, 5.32; 95% CI, 1.53-18.52). There were no statistically significant associations between low IOP and time to reoperation (hazard ratio [HR], 0.73; 95% CI, 0.32-1.68), vision loss (HR, 1.77; 95% CI, 0.81-3.88) or surgical failure (HR, 1.14; 95% CI, 0.62-2.11). In patients with low IOP, there was a higher unadjusted incidence of bleb revision in patients who had maculopathy (7.6 vs. 1.9 revisions/100 person-years; for maculopathy versus no maculopathy P = 0.008). CONCLUSIONS: The absence of laser suture lysis and surgeon are factors potentially associated with low IOP after trabeculectomy. Numeric hypotony does not necessarily represent clinical failure after trabeculectomy.

Glaucoma drainage device surgery in children and adults: a comparative study of outcomes and complications.

PURPOSE: To compare the postoperative outcomes and complications of glaucoma drainage device (GDD) surgery in pediatric (<18 years old) and adult patients. METHODS: Retrospective, comparative study including all patients who underwent Baervedlt or Molteno device surgery by the same surgeon. Success criteria included postoperative intraocular pressure (IOP) between 6 and 21 mmHg and a 20% reduction from baseline. RESULTS: Fifty-two children (69 eyes) and 130 adults (145 eyes) were included. Mean IOP and number of medications were significantly reduced postoperatively in both groups. Overall failure rate was similar in children and adults. However, GDD failed earlier in adults than in children. Hypotony was the most common complication in both groups in the first 6 months postoperatively. Later on, bleb encapsulation was more frequent in children, while corneal decompensation tended to be more frequent and occurred earlier in adults. Children also had a higher rate of infectious endophthalmitis and required tube repositioning more frequently than adults. CONCLUSIONS: GDD surgery presents different postoperative challenges in children and adults, and the surgeon should remain vigilant for complications throughout the postoperative period, especially for signs of endophthalmitis or bleb encapsulation in pediatric patients. On the other hand, adults may be more prone to early corneal decompensation.

Is Multiple Sclerosis Associated With a Lower Intraocular Pressure?

OBJECTIVE: To determine if multiple sclerosis (MS) is associated with lower intraocular pressure (IOP) compared with individuals without MS. METHODS: Thirty patients with clinically definite MS were identified and a retrospective chart review was conducted. Each patient with MS underwent IOP recording by a single investigator using kinetic applanation tonometry. Measurement of central corneal thickness (CCT) also was obtained. Similarly, 30 study controls were identified and kinetic applanation tonometry and CCT were recorded. Univariate analysis of covariance was conducted to determine a statistically significant difference between IOP between MS and control groups, controlling for age. RESULTS: Analyses were adjusted for age and 2 subjects were excluded because of steroid use. The average IOP in MS group was 12.3 mm Hg (right eye = 12.3 mm Hg, left eye = 12.2 mm Hg) and in the control group was 17 mm Hg (right eye = 16.9 mm Hg, left eye = 17 mm Hg). There was a significant effect of presence of MS on IOP accounting for 53% variability in mean IOP (F(1,55) = 60.7; P < 0.001) when compared with the control group. CONCLUSIONS: This study demonstrated that IOP was significantly lower in patients with MS compared with controls. A more in-depth prospective study design is required, along with further investigation of possible etiologies. Identifying the mechanism of decreased IOP in patients with MS might allow development of new-targeted therapies for the treatment of glaucoma.

Cyclodialysis: an update.

Cyclodialysis is the result of the separation of the longitudinal ciliary muscle fibers from the scleral spur, which creates an abnormal pathway for aqueous humor drainage that may lead to ocular hypotony. For many years cyclodialysis was considered a treatment option for glaucoma. However, today it usually occurs as a complication of blunt trauma or more rarely as a complication of anterior segment ocular surgery. Ocular hypotony can lead to cataract development, optic disk swelling, refractive changes, and several retinal complications, making accurate identification and timely intervention of the cleft mandatory. Traditionally gonioscopy was the only available technique to diagnose and localize the cleft. However, other tests such as optical coherence tomography, magnetic resonance imaging, transillumination, and specially ultrasound biomicroscopy are now available for the diagnosis of cyclodialysis. Multiple treatment options are also available for this condition. Although medical treatment can be effective to close small clefts, surgery is needed in most patients to restore ocular pressure.